IDS/HEALTH INFORMATION BULLETIN
WHO Country Office for Uganda
in collaboration with Great Lakes Epidemiological Bloc
June 2002 No. 5.
Integrated Disease Surveillance and Response (IDSR)
Improving EPI performance in Uganda ....... 1 strategy is key for communicable disease control and
Mortality reporting in Uganda ....................... 2
response to epidemics. At the end of May 2002, Uganda
hosted the 3rd regional IDSR annual taskforce meeting
Dysentery in Uganda ...................................... 2 due to its high commitment to IDSR implementation.
Current status of IDSR in GL countries....... 3 In the coming months, IDSR is going to focus on the
Lab sensitivity analysis in Uganda ............... 3 improvement of interventions and response.The initiative
of the Ministry of Health to award prizes to districts with
Essential drug policy in Uganda ................... 4 good performance in EPI activities and HMIS reporting is
in the positive direction. However, there is need for more
Epidemic-prone zones in GL countries....... 4 efforts in strengthening collection, analysis and utilisation of
both morbidity and mortality data for better monitoring
Editorial Team: and evaluation of interventions. The experience of other
Dr. Nestor Ndayimirije WHO - Chairman
Great Lakes countries may serve as an example for
Dr. Josephine Nambooze WHO
improvement in reporting mortality data. Improving access
Dr. Jimmy Kamugisha Min. of Health
to essential drugs for priority diseases in the country will
Dr. Eddy Mukooyo Min. of Health
be the next key support intervention for IDSR.
Mr. Peter Kintu WHO Dr. Oladapo Walker - WR Uganda
Improving EPI Performance in Uganda
THE HEALTH SECTOR STRATEGIC PLAN (2001-05) Using this criteria, the districts in the western and
in Uganda has put strong emphasis on immunisation eastern parts of the country appeared to be doing well
for all Ugandan children below 5 years of age. DPT3 in terms of immunisation coverage and IDS reporting
coverage is one of the key output indicators of the compared with the central and northern districts.
HSSP, with a five-year target set at 80%. The current
data, however, indicates that more than half of the On the whole, the best district (Moroto) scored only 20
districts in Uganda have a DPT3 coverage of less than out of the total score of 30. Therefore, there is need
80% and a DPT1-3 drop-out rate of more than 10%. for more effort and support in revitalising immunisation
Since the beginning of 2001, the Ministry of Health, with coverage and stengthening IDS across the country.
support from WHO and other partners, has initiated a
programme to revitalise immunisation coverage in the Distribution of immunisation performance by district
country to fulfil the HSSP goals.
During the launching of the revitalisation of immunisa-
tion and home-based management of fever in Uganda
in June 2002, ten districts were awarded prizes for
good performance in EPI activities. The assessment
criteria (table below) used mainly data from Integrated
Disease Surveillance for the years 2000 and 2001.
C rite ria fo r se lectio n o f b es t p e rform in g distric ts
N um b er V a ria ble S co re
1 D istricts tha t m ainta in ed D P T 3 cove rag e >
8 0 % for 2 00 0 2 .5
2 D istricts tha t m ainta in ed D P T 3 cove rag e o f
> 8 0 % fo r 2 00 1 2 .5 Key:
3 D istricts w ith fu lly im m u n ized ch ildren fro m 12.5-20.0 Prize winners
1 9 98 /9 E P I co ve rag e su rve ys o f abo ve 6 0% 5
4 D istricts w ith D P T 1 - 3 drop o u t rate < 10 %
fo r 2 001 5 1.0-7.5 Poor
5 Im p ro vem e n t in D P T 3 cove rag e of > 10 % 0.0 Poorest
b e tw een 20 00 a nd 2 0 01 5 New districts, not
6 D istrict tim elin e ss o f re portin g to H M IS o f > considered in selection.
8 0 % in 2 00 1 2 .5
7 D istrict com p le tene ss o f rep o rtin g to H M IS
o f > 80 % in 20 01 2 .5
8 8 0 % of stoo l specim e n s co lle cte d w ith in 14
d a ys for A F P ca se s 5
Source: EPI Team, WHO
9 M e a sles co ve ra ge fo r 2001 w a s use d a s UNEPI, Ministry of Health
th e tie bre a ke r
WHO - I D S/H e a l t h I n f o r m a t i o n B u l l e t i n , June 2 0 0 2
Mortality Reporting in Uganda
MORTALITY DATA from health facilities is crucial for During the dissemination of revised HMIS tools, there
the evaluation of the quality of case management and were no clear instructions about the changes in the
the performance of disease specific programmes. channel of transmission of reports from hospitals and
health centres given the fact that they were not used to
Reporting on mortality data has been lacking for a long reporting to the DDHSís office. In addition to this, the
time in Uganda due to administrative and structural clinicians and record assistants from hospitals who
problems. In the past two decades, reporting tools for are the source of the information were not properly
in-patient, including mortality data were only available sensitized on the new reporting system which de-
for hospitals and reporting was done only on an annual manded reporting through the DDHSís office and on a
basis directly to the Ministry of Health. It was also monthly basis.
noted that the health centres with in-patient services
were not required to report on mortality data. In 1993, Way forward:
Ministry of Health introduced the Health Management
Information System (HMIS) in order to improve the Encourage the use of data generated from the
reporting system but unfortunately mortality data was reporting system, especially at the service delivery
not captured in the HMIS tools on a monthly basis. level.
Organise sensitization sessions for clinicians and
In 1998,during the introduction of IDSR in Uganda, the record assistants on the importance of mortality data
need to review HMIS was highly recognised to include and the new mechanism for reporting.
in the reporting tools the priority diseases as agreed Disseminate clear instructions on reporting
upon by the IDSR committee. In addition, this was also mechanisms to the DDHS by hospitals and health
to respond to the increasing demand from MoH pro- centres with in-patient services.
grammes and partners. After two years of fruitful work Include mortality data in the monthly feedback to
with the various programmes, the revision of HMIS the DDHS.
tools was concluded in July 2001. The periodicity of
reporting was revised from annually to monthly and Since the beginning of the year 2000, other coun-
through the office of the District Director of Health tries in the region (Rwanda, Burundi and Tanza-
Services (DDHS). According to the revision, all health nia) have continuously reported on mortality on a
facilities with in-patient services were included in the monthly basis. Although Uganda has performed
reporting system. Furthermore, introduction of monthly very well in weekly epidemiological reporting, the
mortality reporting would ease the work of records MoH needs to improve on monthly mortality data
assistants who originally had to compile yearly totals. reporting using the experience from other coun-
So far, only few districts (5) have started reporting
on mortality data.
Dysentery in Uganda
DYSENTERY continues to be one the key epidemic- types of dysentery. Some districts send stool speci-
potential diseases in Uganda. The Epidemiological mens to Regional Referral Laboratories and the
Surveillance Division of the Ministry of Health has
provided a simple case definition for bacillary dysentery Central Public Health Laboratory for confirmation. It is
to all health workers in Uganda as ëany person having recommended to put more effort in processing labora-
diarrhoea with visible blood in the stool and usually tory specimens at the beginning of the outbreak in
accompanied with abdominal painí. The alert and order to confirm and establish drug sensitivity.
action thresholds have been defined as ëan increasing
trend in the number of cases of bloody diarrhoeaí and The epidemic trend suggests a seasonal increase
ëany increase in number of deaths due to bloody diar- and a rising magnitude which calls for indepth as-
rhoeaí respectively. sessment of dysentery in order to initiate appropriate
During the past 3 years, high incidence levels of bacil-
lary dysentery have been observed in the first quarter Trend of Dysentery in Uganda 1999-2002
of each year. This coincides with the onset of the first
rain season, and probably poor sanitation and hygiene 10000
practices in many parts of the country contribute to the 9000
prevalence of the disease. The general trend, however, 8000
indicates that cases of bacillary dysentery are on the 7000
increase in the country. A four-fold increase in the 6000
number of cases has been registered between Janu- 5000
ary 1999 (2,300) and January 2002 (8,300). Current
data from the weekly epidemiological reports indicate
that 54 out of 56 districts are reporting dysentery 1000
The majority of the reported cases are clinically diag- Month
nosed, but this broad definition may contain other
Source: Resource Centre, Ministry of Health
WHO - I D S/H e a l t h I n f o r m a t i o n B u l l e t i n , June 2 0 02 2
Cur r ent status of IDSR implementation in GL Countries
IDSR Indicator Burundi DR Congo Rwanda Tanzania Uganda
In the Great Lakes region, the introduction of Inte- 1. HF submitting timely 20% 70% 50% 61%
grated Disease Surveillance and Response (IDSR) surveillance reports
2. Reported outbreaks 0% 100% 90% -----
strategy started in Tanzania at the end of 1998. So far, of epidemic-prone
diseases notified to the
the other countries started the implementation of this next level within 2
strategy in year 2000. Currently, the overall implemen- days of surpassing the
epidemic threshold in
tation level of the IDSR process is about 52%. The 2001
3. Cases of disease 33% 25% 100% 50%
variables used for this estimation are the major steps targeted for
for IDSR implementation, establishment of IDSR reported using case-
structures at country level, basic equipment and some based forms or line
important functions for IDSR (see table below). 4. Investigated 59.4% 100% 5% 47%
Status of IDSR strategy implementation in GL Countries outbreaks reported
with case-based data
Achievements Burundi DR Congo Rwanda Tanzania Uganda Remarks in 2001.
1. Conducted sensitization yes yes yes yes yes 5/5 5. Districts that have 60% 100% 25% 80%
2. Conducted assessment no yes yes yes yes 4/5 current trend analysis
3. Developed IDSR plan no yes yes yes yes 4/5
for selected priority
4. Adapted IDSR guidelines no no Yes yes yes 3/5
5. Adapted IDSR training no no no yes no 1/5 diseases.
modules 6. Reported outbreaks 54% 100% 90% 76%
6. Started implementation no no yes yes yes 3/5 of epidemic-prone
7. Established IDSR no no yes yes yes 3/5 diseases that occurred
committee in 2001 with lab
8. Designated IDSR focal 0/2 0/2 0/2 2/2 2/2 4/10
point (provincial/ district confirmation results.
and HF) (2)
9. Has equipment 2/2 0/2 0/2 2/2 2/2 6/10 Way forward: Source: MoH
(computer, e-mail) (2)
10. Has Data Manager/stat Yes No No No Yes 2/5 Use the experiences and success stories to accel-
11. Has bulletin 1/2 0/2 0/2 0/2 1/2 2/10
(weekly/monthly) (2) erate the implementation process.
12. Established lab No no no Yes yes 2/5
networking Countries with security problems (Burundi, DR
On the status of IDSR implementation using the core Congo), could implement IDSR in relatively peaceful
indicators, a questionnaire was filled by MoH and the areas .
results are presented in the following table. By the end Accelerate the establishment of laboratory network-
of 2002 (3 years of implementation), an indepth evalu- ing.
ation should be done by a joint team of WHO and MoH Conduct a formal evaluation using IDSR core
in the different countries in order to appreciate the indicators to assess what is happening down-
level of implementation of IDSR downstream (provin- stream (provincial or district level) by the end of
cial or district level). 2002.
Lab Networking: Analysis of Drug Sensitivity in Uganda
Following IDSR implementation in Uganda and with Cotrimoxazole and ampicillin, easily available over the
support from WHO, laboratory networking has been counter, are ablated from effective drugs. Other than
functional since June 2001. Since then, 9 districts for cholera, tetracycline is also ineffective. Although
have sent samples to the Central Public Health Labo- chloramphenicol showed activity against Salmonella
ratory (CPHL). The samples have been processed typhi, its poor inhibition of Salmonella enteritidis is of
and antibiotic sensitivity tests performed. concern, hence the need to differentiate between
Salmonella typhi and other salmonellae whenever
The following table shows the enteric bacterial patho-
salmonellosis is considered as a diagnosis.
gens reported by the CPHL from the samples. Num-
bers susceptible to the commonly used antimicrobial
These results should contribute to formulation of an
agents are also shown.
effective antibiotic policy for the Ministry of Health.
Antimicrobial Sensitivity of Enteric Bacterial Pathogens with Epidemic Potential in
Pathogen Number of COT AMP TET CHL NAL CIP ERY
Shigella dysenteriae type 1 9 (only 3 tested) 0 0 0 2 3 3 -
COT = Cotrimoxazole
Shigella Flexner 21 0 1 0 1 21 21 -
AMP = Ampicillin
Vibrio-cholerae Inaba 9 0 0 7 0 1 7 7
TET = Tetracycline
Vibrio-cholerae Ogawa 24 0 0 24 0 0 24 24
CHL = Chlorampenicol
NAL = Nalidixic acid
Salmonella enteritidis 26 0 0 0 0 26 26 -
CIP = Ciprofloxacin
Salmonella typhi 3 0 0 1 3 3 3 -
ERY = Erythromycin
Source: Central Public Health Laboratory, MoH.
3 WHO - I D S/H e a l t h I n f o r m a t i o n B u l l e t i n , June 2 0 0 2
Essential Drugs and Medicines Policy in Uganda
Rational Use of Drugs: Treatment guidelines,
In the 2002-2003 biennium, the WHO Country Office dissemination of information and training for
Essential Drugs Management programme focuses on health professionals and consumers, public
support to the Ministry of Health (MoH) for improved and private.
capacity for the National Drug Policy (NDP) implemen-
THE DRUG MANAGEMENT CYCLE:
tation and monitoring. This is in line with the WHO
Global Medicines Strategy of saving lives and improv-
ing health by helping to close the gap between the
potential that essential medicines have to offer and the
reality that for millions of people medicines are unavail-
able, unaffordable, unsafe or improperly used.
WHO will support the MoH to ensure that all Ugandans
can obtain the medicines they need, at a price they
and the country can afford; that these medicines are
safe, effective, and of assured quality; and that they
are prescribed and used rationally.
This work is being guided by 4 objectives outlined The cycle emphasises the relationships between drug
below and within the framework of the drug manage- selection, procurement, distribution, and use activities,
ment cycle. which are nurtured by a strong management support
system. The entire cycle will rest upon the NDP and le-
National Drug Policy: Implementation of the new gal framework that upholds the commitment to an ef-
NDP, which is basically a guide to coordination fective drug supply system for Uganda.
of action by all stakeholders.
Access to Essential Medicines: Selection of In addition specific emphasis is being placed on improv-
drugs, financing, pricing and supply systems. ing access to essential drugs for priority diseases such
Quality and Safety of Medicines: Standards and as HIV/AIDS, TB, Malaria and other Childhood illnesses.
effective regulation by the National Drug Au-
thority (NDA), information support.
Epidemic-prone Zones in the Great Lakes
Disease surveillance, preparedness and response on, very little has been done in the prevention and
have been improved in the Great Lakes Countries. control of epidemics.There is need to mobilise more
This is in comparison with the past 5 years experience financial support from partners in order to initiate
of the Great Lakes Epidemiological Bloc. It has been projects focussed at those zones.
observed that commendable improvement has been
made in disease surveillance in timeliness and com-
pleteness of reporting. As a result, epidemic disease
trends and their magnitude can be monitored in order
to provide response and appropriate actions.
In October of each year, WHO and Ministry of Health
officials from Great Lakes region working in disease
surveillance, preparedness and response meet to
review the progress made in this area. Although re-
markable progress has been made in disease surveil-
lance and information sharing, there are some weak-
nesses in preventive activities and lack of resources to
control the epidemic-potential diseases. Different
actions undertaken in the last five years have led to the
control of epidemics in many regions of different
countries (e.g. cholera), but they are still confined in
few pockets called epidemic-prone zones. These
zones are generally located along border districts or
In the last meeting held in Bujumbura in October 2001,
participants identified six epidemic-prone zones in the
Great Lakes region. The aim was to focus on these Zone A: Around Kigoma on Lake Tanganyika
zones to initiate preventive measures and improve Zone B: Borders DR Congo, Rwanda and Uganda
continuous disease surveillance in order to effectively Zone C: Around Kagera River
control the epidemic-potential diseases in the region. Zone D: Around Lake Ki vu
Zone E: Around Lake Albert
The implementation of preventive and control activities Zone F: Borders Rwanda and Burundi
in these zones has been hindered by lack of re-
sources. Although disease surveillance is still going
WHO - I D S/H e a l t h I n f o r m a t i o n B u l l e t i n , June 2 0 0 2 4